Archdiocese of Galveston-Houston | Catholic Schools Office, 2021 125c
2021-2022 SCHOOL YEAR
To be completed by the Physician/Licensed Examiner
Height: Weight: Pulse: Blood Pressure: ________/_________
Vision R 20/________L 20/________ Corrected: Yes______ No_______ Pupils: Equal ______ Unequal _____
Hearing: Normal_____ Referred_____ Spinal Exam: Normal_____Referred______ % Body Fat (optional)
Lymph nodes
Heart-Auscultation of the heart in the supine
Heart-Auscultation of the heart in the
standing position
Heart-lower extremity pulses
Genitalia (males only)
Cleared for all sports without restriction
Cleared for all sports without restriction with recommendations for further evaluation or treatment for:
Not cleared
Pending further evaluation
For any sport
For certain sports:
Reason: _______________________________________________________________________
Recommendations: _________________________________________________________________________________
Name of Provider: Phone: Date of Exam: ______________
What is a concussion?
A concussion is a brain injury that:
Is caused by a bump, blow, or jolt to the head or body
Can change the way a student’s brain normally functions
Can occur during practice or contests in any sport
Can occur in activities both associated and not associated with the school
Can occur even if the student has not lost consciousness
Can be serious even if a student has just been “dinged” or had their “bell rung”
Are the symptoms of a concussion?
Concussions cannot be seen; however, in a potentially concussed student, one or more of the following
symptoms may become apparent. The student may not “feel right” soon after, a few days after or even
weeks after the injury event.
Headache “Pressure” in the head Nausea Vomiting
Balance problems Dizziness Blurry Vision Double Vision
Sensitivity to Light Sensitivity to Noise Confusion Memory Problems
Difficulty paying attention Feeling sluggish, hazy, foggy or groggy
If you have concerns regarding any of the above symptoms, your doctor should be consulted for further
information and/or examination. Your physician or medical professional can best determine your
student’s physical condition and ability to participate in athletics.
What should students do if they believe that they or someone else may have a concussion?
Students should immediately notify their coach or school personnel.
Student should be examined by appropriate medical personnel of the parent’s choosing. The
medical provider should be trained in the diagnosis and treatment of concussions
If no concussion is diagnosed, the student shall be cleared to return to athletic participation.
If a concussion is diagnosed, the school protocol for return to play from a concussion shall be
enacted. Under no circumstances shall the student be allowed to return to practice or play without
the approval of a licensed medical provider trained in the treatment of concussions.
I have reviewed the above material. I understand the symptoms and warning signs of
CONCUSSIONS. Additional information is available on the Health and Safety page at All concussions should be reported to the school as soon as possible.
Previous concussions should be reported on the Medical History form to allow the medical
practitioner the best information possible when conducting the annual physical examination.
Parent Signature / Date: _____________________________________________
Student Signature / Date: _____________________________________________
CONCUSSIONS Don’t hide it. Report it. Take time to recover.
What is Sudden Cardiac Arrest (SCA)?
Sudden Cardiac Arrest is when the heart stops beating, suddenly and unexpectedly. When this happens
blood stops flowing to the brain and other vital organs. SCA is not a heart attack. A heart attack may
cause SCA, but they are not the same. A heart attack is caused by a blockage that stops the flow of blood
to the heart. SCA is a malfunction of the heart’s electrical system, causing the heart to stop beating.
How common is Sudden Cardiac Arrest?
While studies differ in the actual rate of occurrence, the American Heart Association information
indicates that there are approximately 300,000 SCA events outside hospitals each year in the United
States. About 2000 patients under the age of 25 die of SCA each year. Studies now being performed in
Texas and other states indicate the occurrence rate for high school age athletes may be greater than this
Are there warning signs?
Although SCA happens unexpectedly, some people may have signs or symptoms, such as:
Dizziness Fatigue Lightheadedness
Extreme tiredness Shortness of breath Nausea
Difficulty breathing Vomiting Racing or fluttering heartbeat
Chest Pains Syncope (fainting)
These symptoms can be confusing and unclear in athletes. Often people confuse these warning signs as
physical exhaustion. SCA can be prevented if the underlying causes can be diagnosed and treated.
For this reason these symptoms are included on the Medical History form provided by TAPPS and
required for each student prior to participation in athletic events each year. As parents and student
athletes, your truthful answers to these simple questions will assist your medical practitioner when
performing the annual physical examination.
What are the risks of participation and playing with these symptoms?
Continued participation brings with it increased risk. This includes playing in practices and games.
When the heart stops, so does the blood that flows to the brain and other vital organs. Death or permanent
brain damage can occur in just minutes. Most people who experience a SCA die from the event.
While TAPPS does not mandate Cardiac Screening prior to participation, TAPPS and the TAPPS member
schools recognize the importance of our students’ health and highly recommend discussing screening
options with your healthcare provider. Any student who shows signs of SCA should be removed by the
parents from play. This includes all athletic activity, practices or contests. Before returning to play, the
student should be examined and receive clearance by a licensed health care professional of the parents’
I have reviewed the above material. I understand the symptoms and warning signs of SCA.
Additional information is available on the Health and Safety page at
Parent Signature / Date: _____________________________________________
Student Signature / Date: _____________________________________________
State law prohibits possessing, dispensing, delivering or administering a steroid in a manner not allowed by state
State law requires that only a medical doctor may prescribe a steroid for a person.
State law provides that body building, muscle enhancement or the increase in muscle bulk or strength through the
use of a steroid by a person in good health is not a valid medical purpose.
Any violation of state law concerning steroids is a criminal offense punishable by confinement in jail or
imprisonment in the Texas Department of Criminal Justice.
(source: National Institute on Drug Abuse)
For boys and men shrinking of the testicles, reduced sperm count, infertility, baldness, development of breasts,
increased risk for prostate cancer.
For girls and women growth of facial hair, male-pattern baldness, changes in or cessation of the menstrual
cycle, enlargement of the clitoris, deepened voice.
For adolescents growth halted prematurely through premature skeletal maturation and accelerated puberty
changes. This means that adolescents risk remaining short for the remainder of their lives if they take anabolic
steroids before the typical adolescent growth spurt.
For all ages potentially fatal liver cysts and liver cancer; blood clotting, cholesterol changes, and hypertension
which can promote heart attack and stroke; and acne. Available evidence may suggest that anabolic steroid
abuse, particularly in high doses, promotes aggression that can manifest as fighting, physical and sexual abuse,
and property crimes. Upon stopping anabolic steroids, some abusers may experience symptoms of depressed
mood, fatigue, restlessness, loss of appetite, insomnia, headaches, muscle and joint pain and the strong desire to
return to the use of anabolic steroids.
For Injectors infections resulting from the use of shared needles or non-sterile equipment, including HIV/AIDS,
hepatitis B and C, and infective endocarditis, a potentially fatal inflammation of the inner lining of the heart.
Bacterial infections can develop at the injection site, causing pain and abscess.
I have read the above information and agree that I will not use illegal anabolic steroids.
Student Signature________________________________________________Date______________
I have read the above information and agree to my knowledge my student will not use illegal anabolic steroids.
Parent/Guardian Signature________________________________________Date_______________